Minnesota Nursing magazine
The feeling is mutual
Norman Fifield, 95, has led a rich life, serving in World War II, supporting his family and enjoying a 35-year career in telecommunications.
Today, he lives in an assisted living facility in the Twin Cities with several chronic health conditions that require coordination among members of his care team, who include onsite nurses, a hospice nurse, a social worker, a physician, his daughter and a primary care nurse practitioner.
“The care team revolves around my dad, rather than us driving around town to get him the care that he needs from people who do not communicate with one another,” said his daughter, Barbara Brandt, PhD, associate vice president for education at the University of Minnesota Academic Health Center. “This is the right interprofessional model of care for my dad at the right time.”
Dianne Willer-Sly, DNP, APRN, CNP, sees Fifield at least monthly in his home and communicates often with other members of the care team as well as his daughter. She makes rounds together with her physician colleague, Rachel Burton, DO, who sees residents at the facility on a quarterly basis.
“I see my job as not only the primary care provider, but also as a sort of case manager for my patients,” said Willer-Sly, who also teaches at the School of Nursing. “The buck stops with me. I may call the hospice nurse or bring in the pharmacist for a consultation. I contact specialists occasionally. It’s counterproductive to transport a fragile patient out on a winter day, simply for a routine visit.”
Willer-Sly likes to get to know her geriatric patients well, spending two to three hours with them at the initial visit. She also shares her cell phone number with family members. “We are a team. I like to know what is going on. Did something happen over the weekend? Clear, regular communication is a real advantage and having an informed family member enhances patient care,” said Willer-Sly, who has worked as a nurse practitioner for more than 32 years.
Previously, Fifield’s care was fragmented. “No one was at the center putting all the pieces together,” said Brandt, who directs the National Center for Interprofessional Practice and Education at the University. “Because no one had the total picture of how my dad was doing, he had some devastating falls that may have been prevented with better communication.”
Brandt says her personal experience with her father’s current care team is a model that should be replicated. “Students in the health professions need to see and experience this approach to care,” she said.